DS-160 DRAFT FORM

PERSONAL INFORMATION
Name Provided:
Full Name in Native Alphabet:
Other Names Used:
Telecode Name Used:
Sex:
Marital Status:
Date of Birth:
Country/Region of Birth:
Country/Region of Origin (Nationality):
Do you hold or have you held any nationality other than the one indicated above on
nationality?:
Are you a permanent resident of a country/region other than your country/region of
origin (nationality) above?:
National Identification Number:
U.S. Social Security Number:
U.S. Taxpayer ID Number:

ADDRESS & PHONE INFORMATION

Home Address:
City:
State/Province:
Postal Zone/ZIP Code:
Country/Region:
Same Mailing Address?
Primary Phone Number:
Secondary Phone Number:
Work Phone Number:
Have you used additional phone numbers in the last five years?
Email Address:
Have you used additional email addresses in the last five years?
Do you have a social media presence (Example:
Facebook/Instagram/Youtube/Linkedin/Twitter etc,) Yes/No?:
Social Media Provider/Platform (example: Facebook):
Social Media Identifier (your name in Facebook):
Have you used additional social media platforms in the last five years?:
Social Media Provider/Platform:
Social Media Identifier:

PASSPORT & TRAVEL DOCUMENT INFORMATION

Passport/Travel Document Type:
Passport/Travel Document Number:
Passport Book Number:
Country/Authority that Issued Passport/Travel Document:
City where issued:

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State/Province where issued:
Country/Region where issued:
Issuance Date:
Expiration Date:
Have you ever lost a passport or had one stolen?

TRAVEL INFORMATION
Purpose of Trip to the U.S.
Specify:
Have you made specific travel plans?
Intended Date of Arrival:
Intended Length of Stay in U.S.:
Address where you will stay in the U.S. (City, State, Postal/Zip Code):

Person/Entity Paying for Your Trip (If other than yourself; please provide complete
name, contact number and relationship to you):

TRAVEL COMPANIIONS INFORMATION

Persons Traveling with You
Name (1):
Relationship to You:

PREVIOUS U.S TRAVEL INFORMATION

Have you ever been in the U.S.? If yes, provide information on your last five visits:
Date Arrived (1):
Length of Stay:
Date Arrived (2):
Length of Stay:
Date Arrived (3):
Length of Stay:
Date Arrived (4):
Length of Stay:
Date Arrived (5):
Length of Stay:
Do you or did you ever hold a U.S. Driver's License?
Have you ever been issued a U.S. Visa?
Date Last Visa was issued:
Visa Number (Visa number is the 8 digits red font on the lower right part of the visa):
Are you applying for the same type of visa?
Are you applying in the same country or location where the visa above was issued, and
is this country or location your place of principal of residence?
Have you been ten-printed?
Has your U.S. Visa ever been lost or stolen?
Has your U.S. Visa ever been cancelled or revoked?
Have you ever been refused a U.S. Visa, or been refused admission to the United
States, or withdrawn your application for admission at the port of entry?

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Has anyone ever filed an immigrant petition on your behalf with the United States
Citizenship and Immigration Services?(Please give details about the process)

U.S CONTACT INFORMATION

Contact Person Name in the U.S.:
Organization Name in the U.S.:
Relationship to You:
U.S. Contact Address (City, State, Postal/Zip Code):
Phone Number:
Email Address:

FAMILY INFORMATION
Father's Surnames:
Father's Given Names:
Father's Date of Birth:
Is your father in the U.S.?
Status:
Mother's Surnames:
Mother's Given Names:
Mother's Date of Birth:
Is your mother in the U.S.?
Do you have any immediate relatives, not including parents in the U.S.?
Relative Name (1):
Relationship to you:
Status (CITIZEN/PERMANENT RESIDENT/NONIMMIGRANT/DO NOT KNOW):

Spouse's Full Name:

Spouse's Date of Birth:
Spouse's Country/Region of Origin (Nationality):
Spouse's City of Birth:
Spouse's Country/Region of Birth:
Spouse’s Address:

WORK/EDUCATION/TRAINING INFORMATION
Primary Occupation:
Present Employer or School Name:
Present Employer or School Address:
City:
State/Province:
Postal Zone/Zip Code:
Country/Region:
Start Date:
Work Phone Number:
Monthly Salary/Income in Local Currency:
Briefly Describe your Duties:

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Were you previously employed?
Employers Name:
Employer Address:
State/Province:
Postal Zone/Zip Code:
Country/Region:
Telephone Number:
Job Title:
Supervisor's Surname
Supervisor's Names:
Employment Date from:
Employment Date to:
BRIEFLY DESCRIBE YOUR DUTIES:

Have you attended any educational institutions at a secondary level or above? If Yes,
Name of Institution:
Address:
City:
State/ Province:
Country Region:
Course of Study:
Date of Attendance from:
Date of Attendance to:

Do you belong to a clan or tribe?

Provide a List of Languages You Speak:
Language Name (1):
Language Name (2):
Have you travelled to any countries/regions within the last five years?
Provide a List of Countries/Regions Visited:
Country/Region(1):
Country/Region(2):
Country/Region(3):
Country/Region(4):
Country/Region(5):

Have you belonged to, contributed to, or worked for any professional, social, or
charitable organization?
Name of Organization (1):
Do you have any specialized skills or training, such as firearms, explosives, nuclear,
biological, or chemical experience?
Have you ever served in the military?
Have you ever served in, been a member of, or been involved with a paramilitary unit,
vigilante unit, rebel group, guerrilla group, or insurgent organization?

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SECURITY & BACKGROUND INFORMATION

- Do you have a communicable disease of public health signifi-

cance? (Communicable diseases of public significance include
chancroid, gonorrhea, granuloma inguinale, infectious leprosy,
lymphogranuloma venereum, infectious stage syphilis, active tu-
berculosis, and others diseases as determined by the Depart-
ment of Health and Human Services.)
- Do you have a mental or physical disorder that poses or is likely to pose a
threat to the safety or welfare of
Yourself or others?
- Are you or have you ever been a drug abuser or addict?

- Have you ever been arrested or convicted for any offense or crime, even
though subject of a pardon, amnesty, or other similar action?

- Have you ever violated, or engaged in a conspiracy to violate, any law relating
to controlled substances?

- Are you coming to the United States to engage in prostitution or unlawful com-
mercialized vice or have you been engaged in prostitution or procuring prosti-
tutes within the past 10 years?
- Have you ever been involved in, or do you seek to engage in, money launder-
ing?
- Have you ever committed or conspired to commit a human trafficking offense
in the United States or outside the United States?

- Are you the spouse, son, or daughter of an individual who has committed or
conspired to commit a human
Trafficking offense in the United States or outside the United States and have
you within the last five years, knowingly benefited from the trafficking activi-
ties?

- Have you knowingly aided, abetted, assisted or colluded with an individual who
has committed or conspired to commit a severe human trafficking offense in
the United States or outside the United States?

- Do you seek to engage in espionage, sabotage, export control violations, or

any other illegal activity while in the United States?

- Do you seek to engage in terrorist activities while in the United States or have
you ever engaged in terrorist activities?

- Have you ever or do you intend to provide financial assistance or other sup-
port to terrorists or terrorist
Organizations?
- Are you a member or representative of a terrorist organization?
- Have you ever ordered, incited, committed, assisted, or otherwise participated
in genocide?

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 - Have you ever committed, ordered, incited, assisted, or otherwise participated
in torture?

- Have you committed, ordered, incited, assisted, or otherwise participated in ex-

trajudicial killings, political killings, or other acts of violence?

- Have you ever engaged in the recruitment or the use of the child soldiers?

- Have you, while serving as a government official, been responsible for or di-
rectly carried out, at any time, particularly severe violations of religious free-
dom?
- Have you ever been directly involved in the establishment or enforcement of
the population controls forcing a woman to undergo an abortion against her
free choice or a man or a woman to undergo sterilization against his or her free
will?

- Have you ever been directly involved in the coercive transplantation of human
organs or bodily tissue?

- Have you ever sought to obtain or assist others to obtain a visa, entry into the
United States, or any other United States immigration benefit by fraud or will-
ful misrepresentation or other unlawful means?

- Have you ever withheld custody of a U.S. citizen child outside the United
States from a person granted legal custody by a U.S. court?